As the world anxiously awaits a vaccine for COVID-19, an ethical debate rages over whether people should be allowed to refuse it.

“The ethical question is how coercive the state should, or can, be to immunize as many people as possible,” says Philip M. Rosoff, MD, MA, professor emeritus of pediatrics and medicine at Duke University and former chair of the Duke Hospital Ethics Committee. A person’s right to go unvaccinated “is by no means inviolate, as numerous long-standing public health laws attest,” adds Rosoff. “Societal views on this are interesting in the current context.”

Some people will not be able to receive the vaccine due to medications, advanced age, or multiple comorbidities. These people would remain susceptible to infection from unvaccinated individuals. “Another way to look at this is by asking: ‘How many free riders, people who could be safely vaccinated but refuse, can we tolerate and still keep the disease under control?’” Rosoff asks.

In this situation, the public good is in clear conflict with individual autonomy. “If selfishness does not submit to altruism, or even enlightened self-interest, then the public health need to vaccinate as many people as possible may be doomed,” Rosoff says.

The authors of two recent papers examined how vaccine refusers and vaccine-hesitant families affect medical practices.1,2 “From the clinical perspective, many pediatricians who argue against the practice make the point that it is probably ultimately not in the best interest of children to punish them for their parents’ poor choices,” says Sean O’Leary, MD, MPH, a co-author of both papers.

On the other hand, some pediatricians strongly believe it is an ethical imperative to dismiss vaccine refusers. “In their experience, parents often agree to get their child vaccinated when faced with such a strong policy,” says O’Leary, a pediatrician and pediatric infectious disease specialist at Children’s Hospital Colorado in Aurora.

Many questions still need to be answered. “We don’t know what impact dismissal policies have on trust in healthcare professionals, and medicine in general,” O’Leary offers.

It is unclear if dismissal policies increase or decrease vaccination uptake. “We don’t know much about where children who are dismissed end up getting medical care, or if they get medical care at all,” O’Leary adds.

In the United States, there always has been tension between individual rights and more communitarian views. “One could argue that this tension is even greater now than it has been in many decades,” Rosoff offers.

After recent measles outbreaks, some states have eliminated non-medical vaccine exemptions for school attendance. “Even valid medical excuses are subject to state medical board scrutiny if there is reason to believe they are the product of doctors who give them out too freely,” Rosoff observes.

Thus far, at least, says Rosoff, “the public backlash for vaccine refusers has been pretty minimal, as far as I can tell.” The public’s perception of vaccine refusers appears sharply divided, with two distinct points of view.

“We are seeing a segment of the public that’s becoming more sympathetic to the anti-vaccine groups,” says Dorit Rubinstein Reiss, PhD, professor of law at UC Hastings College of the Law in San Francisco.

For certain people, backlash against state lockdowns served as a kind of “gateway” to a vaccine refusal stance. Individuals who view the pandemic response as a huge government overreach may be likely to reject mandated vaccines.

The second group takes a dim view of vaccine refusal in the context of a public health emergency. “If people know someone who died from COVID, those people are going to be a lot more hostile to efforts to undermine public health measures,” Reiss says.

Which view ultimately dominates the public perception of vaccine refusers depends in large part on how much of a threat the virus is perceived. If it is viewed as largely under control, people will be more accepting of those who want to refuse vaccines. If fear escalates, society as a whole is going to be less tolerant of those who refuse vaccines.

As for healthcare workers, Reiss says it is ethical to mandate vaccinations for two reasons. First, they chose a profession with an obligation to put patients’ welfare above the provider’s. Secondly, says Reiss, “they are already highly regulated. They need to pass licensing requirements and already follow a lot of safety rules. Adding one more regulation doesn’t dramatically change the situation.”

An overriding concern to all of this is the vaccine must meet safety standards. “As long as regulators do their job and it’s safe, it’s perfectly ethical to mandate that healthcare workers take it,” Reiss offers.

Ethics are in the forefront regardless of whether a COVID-19 vaccine ends up mandated or optional. “There’s an ethical imperative to make sure that people continue to treat each other as people,” Reiss notes. “We need to stay conscious of the fact that competing values deserve respect.”


  1. Garcia TB, O’Leary ST. Dismissal policies for vaccine refusal among US physicians: A literature review. Hum Vaccin Immunother 2020;16:1189-1193.
  2. Williams JTB, O’Leary ST, Nussbaum AM. Caring for the vaccine hesitant family: Evidence-based alternatives to dismissal. J Pediatr 2020; May 22. doi: 10.1016/j.jpeds.2020.05.029 [Online ahead of print].